Provider Demographics
NPI:1003289935
Name:ROSE, CRYSTAL RENE (CNM)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:RENE
Last Name:ROSE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:RENE
Other - Last Name:TRAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:7016 BRYANT IRVIN RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4120
Mailing Address - Country:US
Mailing Address - Phone:817-377-8820
Mailing Address - Fax:817-377-8450
Practice Address - Street 1:7016 BRYANT IRVIN RD STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4120
Practice Address - Country:US
Practice Address - Phone:817-377-8820
Practice Address - Fax:817-377-8450
Is Sole Proprietor?:No
Enumeration Date:2015-10-30
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP128269367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife